Provider First Line Business Practice Location Address:
4240 YELLOWSTONE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-2020
Provider Business Practice Location Address Fax Number:
208-238-2069
Provider Enumeration Date:
03/28/2011